Medical College of Georgia Augusta, GA, United States
Amit R. Hudgi, MBBS1, Isaac E. Perry, DO1, Michael Coles, MD1, Kenneth J. Vega, MD2 1Medical College of Georgia, Augusta, GA; 2Augusta University-Medical College of Georgia, Augusta, GA
Introduction: Walled-off pancreatic necrosis (WOPN) is a known complication of pancreatitis. It can be further complicated by infection, hemorrhage, and rarely fistulization. Here we present a rare case of WOPN with duodenal fistulization.
Case Description/Methods: A 65-year-old African-American female with a past medical history of type-II diabetes mellitus, hypothyroidism, chronic kidney disease, morbid obesity (BMI-60), and heart failure was admitted to the hospital with new-onset abdominal pain. She described the pain as sharp, epigastric, 10/10 in severity, non-radiating as well as associated with nausea and vomiting. Of note, the patient was previously admitted to our hospital, approximately 6 weeks earlier, with similar pain and diagnosed with diabetic ketoacidosis and acute pancreatitis. On examination, the patient was afebrile and tachycardic with other vital signs normal. Physical examination revealed a diffusely tender abdomen to palpation, limited by morbid obesity. Significant laboratory values included creatinine of 1.73 mg/dL, glucose of 276 mg/dL, albumin of 3.1 g/dL, and lipase of 78 U/L. No signs of systemic illness were identified. Computerized tomography (CT) scan of the abdomen showed a 10.6 x 6.8 x 9.5 cm region of WOPN (figures A & B). It also revealed WOPN extending into the small bowel wall at the junction between the fourth portion of the duodenum and the ligament of Treitz (figure C). The patient was treated conservatively with the resolution of her WOPN.
Discussion: WOPN is a fairly common complication of pancreatitis. It is a collection of pancreatic and/or peripancreatic necrosis with a defined inflammatory wall. The majority of patients with WOPN are asymptomatic and present with localized abdominal distension. Other symptoms include abdominal pain, nausea, vomiting, or jaundice. When infected, patients present with severe abdominal pain, fever, and other signs of sepsis. Enteric fistulae are a rare complication of pseudocysts. Most of the reported enteric fistulae are at the transverse colon or splenic flexure. Duodenal fistulization of WOPN is extremely rare with few cases reported and mainly result after infection of the necrotic material. This case reinforces that enteric fistulae can be managed conservatively, if not infected, allowing drainage into the bowel. Endoscopic intervention should only be considered in cases refractory to conservative therapy or if the patient demonstrates any clinical deterioration such as infection.
Figure: Figure – A & B: Computerized tomography (CT) scan of the abdomen showed 10.6 x 6.8 x 9.5 cm region of walled off necrosis forming pancreatic pseudocystn.
Figure – C: A region of walled off necrosis appearing to extend into the wall of the small bowel at the junction between the fourth portion of the duodenum and the ligament of Treitz.
Amit Hudgi indicated no relevant financial relationships.
Isaac Perry indicated no relevant financial relationships.
Michael Coles indicated no relevant financial relationships.
Kenneth Vega indicated no relevant financial relationships.
Amit R. Hudgi, MBBS1, Isaac E. Perry, DO1, Michael Coles, MD1, Kenneth J. Vega, MD2. P1142 - Less Is More: Duodenal Fistulization from Walled off Pancreatic Necrosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.